Provider Demographics
NPI:1235422502
Name:GOODRICH, SHEA M (MD)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:M
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:205 MARION PIKE
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-3165
Practice Address - Country:US
Practice Address - Phone:740-532-1183
Practice Address - Fax:740-532-1188
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH123093208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV4337DMedicare PIN
WVWV4337BMedicare PIN
WVWV4337CMedicare PIN
WVWV4337AMedicare PIN